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RESUME
ASUHAN KEPERAWATAN DI RUANG POLI ORTHOPEDI DAN
TRAUMATOLOGI RSD dr. SOEBANDI JEMBER
Oleh:
FIKRI ULIL ALBAB, S.Kep.
NIM. 092311101007
PROGRAM PENDIDIKAN PROFESI NERS
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS JEMBER
2014
RESUME
ASUHAN KEPERAWATAN DI RUANG POLI MATA
RSD dr. SOEBANDI JEMBER
Oleh:
FIKRI ULIL ALBAB, S.Kep.
NIM. 092311101007
PROGRAM PENDIDIKAN PROFESI NERS
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS JEMBER
2014
ASUHAN KEPERAWATAN PADA PASIEN DENGAN SPINAL CORD
INJURY FRAKTUR COMPRESI THORAKAL XI-XII DI RUANG BEDAH
ORTHOPEDI (SERUNI) RDS dr. SOEBANDI JEMBER
Disusun guna memenuhi tugas Program Pendidikan Profesi Ners (PPPN)
Stase Keperawatan Medikal Bedah
Oleh
Fikri Ulil Albab, S.Kep.
NIM.092311101007
PROGRAM PENDIDIKAN PROFESI NERS
PROGRAM STUDI ILMU KEPERAWATAN
UNIVERSITAS JEMBER
2014
PERSETUJUAN
Asuhan Keperawatan Pasien dengan ________________________________
telah dilaksanakan pada tanggal ______________ di Ruang _____________
RSD Dr. Soebandi Jember.
Jember, _________ 2014
Pembimbing Ruangan Pembimbing Akademik
( …………..........………… ) ( …............………………. )
Kepala Ruangan,
( …………………………………)
PROGRAM STUDI ILMU KEPERAWATAN UNIVERSITAS JEMBERFORMAT PENGKAJIAN KEPERAWATAN MEDIKAL BEDAH
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
I. Identitas KlienNama : No. RM :Umur : Pekerjaan :Jenis Kelamin : Status Perkawinan :Agama : Tanggal MRS :Pendidikan : Tanggal
Pengkajian:
Alamat : Sumber Informasi :
II. Riwayat Kesehatan1. Diagnosa Medik:
………………………………………………………………………….................................………………..
2. Keluhan Utama:……………..………………………………………………………………………….………....……………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Riwayat penyakit sekarang: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...................................................................................................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………................
4. Riwayat kesehatan terdahulu:a. Penyakit yang pernah dialami:………………………………………………………………………….................................………………………………………………………………………………………………………………………..………………………………………………………………………………………………………………….………………………………………………………………………………………………………………….………………………………………………………………………….................................………………..b. Alergi (obat, makanan, plester, dll):………………………………………………………………………….................................………………..
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..c.Imunisasi:………………………………………………………………………….................................………………..……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
d.Kebiasaan/pola hidup/life style:………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..
e. Obat-obat yang digunakan:………………………………………………………………………….................................………………..…………………………………………………………………………………………………………………………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..………………………………………………………………………….................................………………..
5. Riwayat penyakit keluarga:………………………………………………………………………….................................………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................………………..
Genogram:
III. Pengkajian Keperawatan1. Persepsi kesehatan & pemeliharaan kesehatan
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
2. Pola nutrisi/ metabolik (ABCD)- Antropometeri
………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Biomedical sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Clinical Sign : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………
- Diet Pattern :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Interpretasi : ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Pola eliminasi: BAK
- Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu- Lain : ……………………………………………………………………………..
BAB - Frekuensi :…………………………………………………………………………….. - Jumlah :……………………………………………………………………………..- Konsistensi : ……………………………………………………………………………..- Warna : ……………………………………………………………………………..- Bau : ……………………………………………………………………………..- Karakter : ……………………………………………………………………………..- BJ :…………………………………………………………………………….. - Alat Bantu : ……………………………………………………………………………..- Kemandirian : mandiri/dibantu - Lain : ……………………………………………………………………………..
Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4. Pola aktivitas & latihan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
c.1. Aktivitas harian (Activity Daily Living)Kemampuan perawatan diri 0 1 2 3 4Makan / minumToileting Berpakaian Mobilitas di tempat tidurBerpindah Ambulasi / ROM
Status Oksigenasi : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi kardiovaskuler : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Terapi oksigen : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
5. Pola tidur & istirahatDurasi : ……………………………………………………………………………………………………Gangguan tidur : ……………………………………………………………………………………….Keadaan bangun tidur : ………………………………………………………………..……………Lain-lain : …………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
6. Pola kognitif & perceptualFungsi Kognitif dan Memori : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi dan keadaan indera : ……………………………………………………………………………………………………………………………………………………….....................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
7. Pola persepsi diriGambaran diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Identitas diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Harga diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Ideal Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Peran Diri : ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
8. Pola seksualitas & reproduksiPola seksualitas ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Fungsi reproduksi …………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
9. Pola peran & hubungan……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….................................................................................................................................................................................................................................................................................................................................................Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
10. Pola manajemen koping-stress……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
11. System nilai & keyakinan…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
IV. Pemeriksaan FisikKeadaan umum:……………………………………………………………..……………………………..........................................……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Tanda vital:
- Tekanan Darah : mm/Hg- Nadi : X/mnt- RR : X/mnt- Suhu : C
Interpretasi : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…………………………………………………………………………
Pengkajian Fisik (Inspeksi, Palpasi, Perkusi, Auskultasi) 1. Kepala
…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
2. Mata …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
3. Telinga.…………………………………………………………………………………….........................................………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
4. Hidung…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
5. Mulut………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
6. Leher……………………………………………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
7. Dada.………………………………………………………………………………………...….…………………………………………………………………………………………...…………………………………………………………………………………………………………………………………………………………………………………………
8. Abdomen……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
9. Urogenital………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
10. Ekstremitas……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
11. Kulit dan kuku……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
12. Keadaan lokal………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
V. Terapi.................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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VI. Pemeriksaan Penunjang & Laboratorium..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Jember, April 2014
Pengambil Data,
(_________________________________)
RENCANA TINDAKAN KEPERAWATAN
Diagnosa Keperawatan Tujuan dan Kriteria hasil Rencana Tindakan Keperawatan Rasional
FORMAT RESUME KASUS KELOLAAN HARIAN
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
IDENTITAS PASIENNama :Umur :Jenis Kelamin :Agama :Pendidikan :Pekerjaan :Alamat :No. RM :Ruangan :Diagnosa Medis :
S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P(Perencanaan):..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I (Implementasi):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E (Evaluasi):S (Subjektif): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Jember, ____________ 2014
Petugas pelaksana,
(_________________________________)
FORMAT RESUME KASUS KELOLAAN HARIAN
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
IDENTITAS PASIENNama :Umur :Jenis Kelamin :Agama :Pendidikan :Pekerjaan :Alamat :No. RM :Ruangan :Diagnosa Medis :
S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P(Perencanaan):..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I (Implementasi):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E (Evaluasi):S (Subjektif): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Jember, ____________ 2014
Petugas pelaksana,
(_________________________________)
FORMAT RESUME KASUS KELOLAAN HARIAN
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
IDENTITAS PASIENNama :Umur :Jenis Kelamin :Agama :Pendidikan :Pekerjaan :Alamat :No. RM :Ruangan :Diagnosa Medis :
S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P(Perencanaan):..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I (Implementasi):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E (Evaluasi):S (Subjektif): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Jember, ____________ 2014
Petugas pelaksana,
(_________________________________)
FORMAT RESUME KASUS KELOLAAN HARIAN
Nama Mahasiswa :NIM :Tempat Pengkajian :Tanggal :
IDENTITAS PASIENNama :Umur :Jenis Kelamin :Agama :Pendidikan :Pekerjaan :Alamat :No. RM :Ruangan :Diagnosa Medis :
S (Subjektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif):......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
A(Analisa/Diagnosa Keperawatan yang ditegakkan berdasar DS dan DO):.............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P(Perencanaan):..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................I (Implementasi):.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
E (Evaluasi):S (Subjektif): ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
O (Objektif): .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................A (analisa): .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
P (Perencanaan: .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Jember, ____________ 2014
Petugas pelaksana,
(_________________________________)